Pubdate: Sun, 18 Mar 2012
Source: Denver Post (CO)
Copyright: 2012 The Denver Post Corp
Contact:  http://www.denverpost.com/
Details: http://www.mapinc.org/media/122
Author: Michael Booth
Bookmark: http://www.mapinc.org/oxycontin.htm (Oxycontin/Oxycodone)

Prescription Drug Abuse

PAINFUL ADDICTIONS

As Hard As It Is for People to Quit Using - and Abusing- Prescription 
Opioids to Attack Chronic Pain, Doctors Are Having a Similarly 
Difficult Time Getting Away From Their Long-Utilized Options for Treatment.

Deaths linked to prescription opioid use have doubled in 10 years in 
Colorado, and the steep increases in both legal use and dangerous 
abuse of painkillers are forcing the medical community to rethink the 
way it treats chronic pain.

Painkiller prescriptions written by the top 10 Medicaid prescribers 
for one popular drug, Roxicodone, shot up 46 percent last year, 
according to state records. Denver's Office of Drug Strategy found 
that prescriptions filled for oxycodone rose 58 percent from 2007 to 2011.

Nonmedical use of painkillers in Colorado is 19 percent higher than 
the national average, according to the Centers for Disease Control 
and Prevention. To illustrate the "epidemic" nature of opioid abuse, 
the CDC said enough of the painkillers were sold in 2010 to medicate 
every American adult with a typical 5-milligram dose of hydrocodone 
every four hours for a month.

"People think, 'It's a pharmaceutical, it's pure, it's good for me.' 
That lends itself to a casualness about the use of it," said Art 
Schut, deputy director of the Arapahoe House addiction-treatment 
center in Thornton. Patients learn too late that opioids are severely 
addictive, in part because of their ability to both block pain and 
induce euphoria. The number of Arapahoe clients coming in for opioid 
dependency or addiction has doubled in four years, Schut said. Those 
kinds of numbers have raised questions about a pain-care philosophy 
that began more than a decade ago. Doctors say using opioid-based 
pills to treat lingering pain helped millions of people. But they 
increasingly acknowledge mounting abuse requires a safety overhaul of 
their practices.

State epidemiologists say opioid-related deaths in Colorado rose from 
182 in 2000 to 421 in 2009, before retreating some. The 2011 count is 
at least 362 deaths, although the year's review of death certificates 
is not yet complete.

Opioids for patients in real need "are far and away the most 
effective treatments in many cases," said Thomas French, a senior 
instructor in the University of Colorado School of Medicine's 
Department of Pharmacology. "But they are very dangerous."

A good portion of the problem for doctors and their patients, French 
said, is "well-intentioned misuse. They don't realize all the dangers 
and extra care you need to take with opioids."

Kaiser moving aggressively

Kaiser Permanente in Colorado is among those moving aggressively to 
reform painkiller prescribing and dispensing.

The nonprofit HMO launched a review in January of every painkiller 
patient in its database. The review spit out lists of patients with 
complicating risk factors, such as other prescriptions for anxiety 
drugs or a family history of dependence. The system, covering 535,000 
patients and 900 doctors, told each doctor to meet with those on the 
list within 60 days.

The Kaiser review, more possible in a tightly controlled HMO system 
with extensive electronic records on each patient, coincided with the 
highly publicized death of pop diva Whitney Houston. Houston, only 
48, had a history of substance abuse, and investigators found 
unspecified prescriptions in her hotel room just before February's 
Grammy Awards.

Kaiser's new Castle Rock medical office is experimenting with other 
ways of ensuring that patients use painkillers legitimately without 
growing dependent, or giving or selling the drugs to others. Castle 
Rock won't dispense opioids on Mondays or Fridays, after doctors 
found troubled patients exploited the busiest prescription-filling 
days to seek extra pills. The Castle Rock doctors now keep a log of 
legitimate upcoming painkiller refills to avoid confusion when a 
patient's doctor is on vacation.

Signed agreements requiredAll Kaiser offices require signed 
agreements with opioid patients, including Kaiser's right to use 
random urine tests to check on patient compliance and overall health.

"Our main focus was to try to control painkiller use, instead of it 
controlling us," said Dr. David Craigie, medical chief at the Kaiser 
Castle Rock clinic.

Kaiser doctors have also tried to make their pain interviews more 
specific, hanging a chart in every exam room with a 1-to-10 scale of 
pain: 8, for example, means severe, "not able to leave my home ... I 
am in bed."

Plenty of doctors have tales about pain-medication abuse. Craigie 
recently took a call from a patient who was running out of a 
painkiller 10 days before it was due to be refilled. In an e-mail 
exchange, Craigie asked whether family members might be taking the 
drugs, a common abuse. The patient soon wrote back and said a 
relative was caught in the act of emptying the pill bottle.

One of Craigie's Castle Rock colleagues, Dr. Howard McGowan, 
mentioned a troubling patient whose demeanor caused him to check the 
name against a state database listing all controlled-substance 
prescriptions. The patient "had been to pharmacies all over the metro 
area every day for 45 days" getting multiple prescriptions, McGowan said.

Colorado is considered among the state leaders in providing access to 
the database to avoid such trouble, but checking it is voluntary with 
each new prescription request.

A growing collection of national voices is urging all pain doctors to 
take similar aggressive measures, without cutting off care to an 
estimated 100 million-plus people suffering "uncontrolled pain."

"Opioids can be life-changing, so how do we prevent diversion? That's 
the issue," said Dr. Paul Christo, a Johns Hopkins University 
physician and researcher who recommends wider use of urine screens.

"All of us who prescribe opioids need to take the steps to reduce 
abuse," Christo said. "No one person is completely free of potential 
abuse. So we should test anyone using opioids for more than three months."

Christo and many other pain specialists pair the drug tests with 
simpler measures. Christo asks some patients to bring in their 
remaining pills for a count, to make sure they haven't taken them too 
fast, given them away or sold them to illicit users.

State health plans are also under increased pressure - for medical 
and cost reasons - to check opioid abuse in public clients.

Colorado's Medicaid program has seen sharp increases in the 
painkiller prescriptions written by the top 10 prescribing doctors, 
according to records provided to U.S. Sen. Chuck Grassley of Iowa and 
shared with The Denver Post.

The number of Roxicodone prescriptions in that group rose 46 percent 
from 2010 to 2011, according to the state disclosure. State Medicaid 
officials said some of the increase may be attributable to the 
fast-rising overall patient rolls for Medicaid, but said they are 
also concerned about the trend.

"An indication of a problem""This kind of increase could be an 
indication of a problem," said Dr. Judy Zerzan, chief medical officer 
for Colorado's Department of Health Care Policy and Financing. Zerzan 
said a partial explanation may be the growth in specialized "pain 
clinics" that can lead to concentration of prescriptions.

"(Medicaid) is now looking into the comparisons over time and seeing 
if action is needed," Zerzan said.

State Medicaid focuses its prevention efforts on scouring records for 
patients who seek pills from multiple providers. The state can put a 
"lock" on patients with a history of doctor-or pharmacy-shopping for 
extra pills. Those patients are locked into only one allowed 
pharmacy, which can further screen problems by checking the statewide 
database for conflicting prescriptions.

Colorado does not require signed opioid agreements for Medicaid 
patients, saying it is impractical with a wide variety of doctors, 
and for patients who can't afford treatment delays.

"There is a set of clients that really do need these kinds of drugs, 
and we wouldn't want them to interrupt their therapy," Zerzan said.

There is no current push to make checking the state prescription 
database mandatory before writing or filling any controlled-drug 
order, officials said.

The U.S. Drug Enforcement Agency is not calling for that kind of 
mandate, said Denver special agent Mike Turner. The DEA is currently 
pushing for new pharmaceutical rules that would allow people to turn 
in unused prescription drugs at any time for destruction.

That would broaden an effort currently limited to twice-a-year drug 
"takebacks" by the DEA and local organizations. Health officials 
don't want the public to simply flush unused drugs down the sewer, 
since they can damage water supplies. The takebacks have been 
successful, but the DEA wants to lift the bar on pharmacies taking 
back drugs after they are dispensed.

Many patients use part of a prescription after surgery or other 
short-term pain, then leave the rest sitting in medicine cabinets or 
drawers. "Unfortunately, as adults we've become our kids' source of 
supply for drugs," Turner said.

That kind of unguarded access is a key problem, former addicts agree.

Bryce Moeder got hooked on Oxycontin after back pain from warehouse 
work sent him to prescription-friendly doctors.

"It's amazing how fast your tolerance goes up with these things," 
said Moeder, who after eventually descending into drug theft is now 
in outpatient treatment. "You could measure that daily. When I first 
started taking them, three 20-milligram pills would keep me messed up 
all day. Nine months later I could take six of the 80 milligrams a 
day without even the same effect."

Early in his addiction, Moeder said, he could go to three or four 
urgent clinics in one afternoon for different prescriptions. When 
those grew more connected and shared records, he went down the common 
list of addict access: faking injuries to get new prescriptions from 
pain clinics; searching friends' houses for leftover pills; breaking 
into houses and medicine cabinets; and even following customers out 
of clinics and stealing their prescriptions in the parking lot.

Doctors can help deter illegal use of legal prescriptions with their 
new measures, Moeder said, but they shouldn't simply cut off patients 
who fail a urine test. The addiction is so severe, treatment experts 
agree, dependent patients need to be tapered off opioids with 
replacements and counseling.

Pharmacies also can do more, Moeder said. "Schedule II," or 
restricted, drugs that include opioids should have their dosages and 
pill totals confirmed with the prescriber every time, he suggested. 
That would cut down on patients' altering prescriptions to get more pills.

Clinics can do the most good, Moeder said, by focusing on legitimate 
pain patients who might be on the brink of problems. Hard-core 
addicts will always find a way to get pills.

"It's an epidemic," he said, "and it doesn't seem like it could be 
controlled by one move."

Michael Booth: 303-954-1686,  or twitter.com/mboothDP

[sidebar]

Know your opioids - and how to handle them

The opioid-derived painkiller prescriptions that have grown so much 
in recent years include an array of brand names and generics. They 
are highly prescribed, in part, because they are very effective at 
blocking pain; they are highly addictive because they also flood the 
"reward" pathways of the brain with good feelings, in the same way 
rewards are sent by drinking, eating and intimacy.

The most common forms are morphine, methadone, hydrocodone, fentanyl, 
oxymorphone and oxycodone. The more common names attached to brand 
names or generics include OxyContin, Vicodin, Percocet, Roxicodone, 
Roxanol and, more recently, the Opana version of oxymorphone.

HOW TO GET HELP

For help with questions about painkiller dependency, abuse and 
addiction, go to arapahoehouse.org. Addiction Research and Treatment 
Services, or ARTS, is also a good source. It is located at the 
University of Colorado Anschutz Medical Campus. Go to 
artstreatment.com. Also, the federal government has a substance-abuse 
referral at samhsa.gov and 800-662-HELP.
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MAP posted-by: Jay Bergstrom